A 10-year-old child was admitted with full-thickness burns affecting more than 15% of the child’s body surface. What manifestations of hypovolemic shock would you observe for over the next 48 hrs? Select all choices that apply:
Rapid pulse.
Decreased B/P.
Pallor.
Flushed Face.
Correct Answer : A,B,C
Choice A rationale
Rapid pulse is a common manifestation of hypovolemic shock. When the body experiences a significant loss of fluid, such as in severe burns, the heart rate increases in an attempt to maintain adequate blood flow and oxygen delivery to the body’s tissues.
Choice B rationale
Decreased blood pressure is another typical sign of hypovolemic shock. As the body loses fluid, the volume of blood circulating through the body decreases. This drop in blood volume leads to a decrease in blood pressure.
Choice C rationale
Pallor, or paleness of the skin, can occur in hypovolemic shock. This happens because the body prioritizes sending blood to vital organs like the heart and brain, which can result in less blood flow to the skin, causing it to appear pale.
Choice D rationale
A flushed face is not typically associated with hypovolemic shock. In fact, the skin may actually appear pale or cool due to reduced blood flow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Activated charcoal is often used in the management of poisoning. It works by binding to the poison in the stomach and preventing it from being absorbed into the body14.
Choice B rationale
Osmotic diarrheal agents are not typically used in gastric lavage. These agents work by increasing the amount of water in the intestinal tract, which can stimulate bowel movements14.
Choice C rationale
Syrup of ipecac was once used to induce vomiting in cases of poisoning, but it is no longer recommended for use in poisoning cases14.
Choice D rationale
0.9% sodium chloride, or normal saline, is a type of fluid that’s often used in medical treatments, but it’s not typically used in gastric lavage for poisoning14.
Correct Answer is D
Explanation
Choice D rationale
When a nurse notes the presence of bruises on a child’s arms and legs, the first action should be to obtain a detailed history. This can provide important context for the bruises and help determine whether they are likely the result of accidental injury or possible abuse.
Choice A rationale
Telling the child what will happen when the abuse is reported is not the first action a nurse should take. It is important to first gather all necessary information and report the suspected abuse to the appropriate authorities.
Choice B rationale
Requesting a social services referral is an important step when abuse is suspected, but it should come after obtaining a detailed history and reporting the suspected abuse.
Choice C rationale
Reporting the suspected abuse to the authorities is crucial when child abuse is suspected. However, it is important to first obtain a detailed history to provide as much information as possible to the authorities.
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